Product Order Form
2391 Lexington
Drive
Apt. 208
Mount Prospect, IL
60056
jmspight.blogspot.com
Important: Receipts
will be sent to the customer address along with the product ordered. Please
make your checks or money order out to Jeanine Smith. Mail the order form along
with the payments to 2391 Lexington Drive, Apt. 208, Mount Prospect, IL 60056.
Enter Your Product
Selections Below
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Item Description
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Item Price
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Quantity
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Total
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Bracelet:
Black $5.00____________ _________ $___________
Black and Teal $5.50____________ _________ $____________
Black and Teal with crystal stones $6.00___________ _________ $____________
Teal $5.00____________ _________ $____________
Teal with crystal stones $5.50_____________ _________ $____________
Key Fob:
Black $3.50__________ _________ $____________
Black and Turquoise $4.50___________ _________ $____________
Sub-Total: $____________
Shipping ($2.50): $____________
Grand Total: $_________
Shipping Information
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*First Name: Middle
Initial: *Last Name:
____________________________________
____________________________________
____________________________________
Address Line:* Email address:*
Address Line:* Email address:*
Payment Information
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Payment Method:*
Check Money
Order
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